2.0 Analysis 2.1 Passage Planning and Resource Management There was no prior discussion or planning of the passage down the Black River. The turns in the river and the narrow channel make it a challenging undertaking with little room for error. When outbound from the lower turning basin, a vessel reaches quickly the two bridges which must be raised, and the passage must be planned to allow the vessel to be able to stop if there is a delay with a bridge opening. The routine adopted on the CATHERINE DESGAGNS was for the conduct of the vessel to be entirely in the master's hands, while other officers attended to other duties. Because of this, there was no provision for the officers to back up the master's observations or report navigational errors or concerns to him. In preparing a passage plan, the (vessel's) bridge team would have been aware of the time required to open the highway bridge after acknowledgement of the vessel's signal. Putting this information together with the distances involved would have made it clear that the vessel should not delay making the signal to request that the bridge be opened, and that the vessel was required to proceed at a reduced speed. 2.2 Speed of the CATHERINE DESGAGNS The average speed of the CATHERINE DESGAGNS at 5.5 knots was only marginally greater than the permissible speed limit of 5.2 knots. However, as the vessel did not come to an abrupt stop and, on two occasions, was running the main engine astern and/or dragging an anchor, it is apparent that she significantly exceeded the speed limit for part of the passage. The time at which the vessel passed various points in the river was only recorded to the nearest minute, but this information provides an indication of the vessel's speed over the different sectors and agrees with the other evidence. The engineer on watch stated that he maintained full speed ahead until the movements before the vessel stopped. This would explain the progressive increase in speed that was demonstrated over the sectors. Also, a top speed of at least 10 knots entering the last sector is consistent with the testimony of other witnesses. 2.3 The Outbound Passage Difficulty was experienced at the beginning of the passage when attempting to swing the vessel in the lower turning basin. A manoeuvre which should have required only about half an hour was not completed until about two hours after the CATHERINE DESGAGNS had left the dock. The master stated that he was concerned by the time the manoeuvre was completed. In such a situation, a typical reaction would be to endeavour to speed up the departure procedure, especially if some embarrassment was felt because of the difficulty experienced in turning the vessel. The evidence was that, after leaving the turning basin, the CATHERINE DESGAGNS picked up speed until she was considerably in excess of the speed limit. The evidence was also that the outward passage of the CATHERINE DESGAGNS was not a fully controlled manoeuvre in that the vessel was wide on the turns in the river and could not be brought safely to a stop when approaching the highway bridge. From the information available, it also appears probable that the railway bridge was raised sufficiently to clear the vessel only because the bridge operator had prepared the bridge for lifting ahead of time. The master had retired almost seven years before, after a full working career, and had only been casually employed in the intervening period. In such circumstances, complex cognitive skills are subject to decay because they are not practised regularly. The master stated that, when he was preoccupied with the navigation of the vessel, his concentration was focused ahead, on where the vessel was going. He did not observe several important factors, such as the railway bridge not being fully raised, the railway bridge signal light still being red when the vessel passed through, and the extent of the damage the stern and propeller were causing when backing up in the marina. The instructions from the USCG were also not perceived as such. The failure to recognize critical elements significant to the navigation of the vessel and the less than controlled manner in which the vessel was navigated are considered to be consistent with the behaviour of a person exposed to stress or agitation and experiencing some degree of skill decay. The consequences became critical because the master did not have adequate backup in the form of (vessel) bridge resource management to provide a line of defence against inappropriate actions and reactions. 3.0 Conclusions 3.1 Findings Difficulty was experienced in swinging the CATHERINE DESGAGNS in the designated turning basin, and this delayed the down-river passage. The vessel's speed on the down-river passage increased until it was greater than the local speed limit. The vessel passed under the railway bridge before the bridge had been fully raised, and with the marine traffic signal still set at red. The signals requesting the opening of the two bridges were not made consecutively, and the highway bridge signal was delayed until the final approach. The highway bridge operator could not open the bridge in the limited time available and advised the vessel. The vessel could not be brought to a controlled stop in front of the highway bridge because of her excessive speed. In attempting to stop, the CATHERINE DESGAGNS went out of the channel and into a marina complex, sinking and damaging pleasure craft and dock facilities. Further damage to pleasure craft was inflicted as the CATHERINE DESGAGNS manoeuvred to back up and pass through the opened bridge. There had been no prior discussion or planning of the down-river passage between the master and the vessel's officers. The master did not recognize several critical factors significant to the navigation of the vessel. While the master had the conduct of the vessel, his behaviour was consistent with that of a person experiencing some degree of stress and skill decay. The down-river navigation of the CATHERINE DESGAGNS was carried out in a manner lacking vigilance and precision. 3.2 Causes The CATHERINE DESGAGNS was unable to stop on her approach to a highway bridge in Lorain Harbor because her speed was excessive and greater than the permitted speed limit. The fact that resources available to facilitate the navigation of the vessel were not utilized contributed to the occurrence. 4.0 Safety Action 4.1 Action Taken 4.1.1 Company Procedures As a result of this occurrence, the vessel owners issued the following instructions and procedures to all their masters for piloting the Black River: masters must follow prescribed communication procedures with the bridge operator, and record the conversations; before departure, the master shall communicate with bridge operators regarding the ship's estimated time of arrival at the bridge; both masters and ship officers must conduct passage planning and briefings before departure; a senior navigation officer shall be present to assist the captain in conducting the river passage; and an officer shall be posted to stand by the windlass on the foredeck. 4.1.2 Bridge Resource Management Practice The Board has previously noted that poor communications on the bridge, interrupted procedures, lack of situational awareness, and lack of teamwork continue to be factors in occurrences. Consequently, the Board, in recent reports, has emphasized the need for improved teamwork to advance safe navigation. Furthermore, the Board has just completed a Safety Study of the Operational Relationship Between Ship Masters/Watchkeeping Officers and Marine Pilots in which safety deficiencies were identified associated with teamwork on the bridge, including communications between marine pilots, masters, and watchkeeping officers. In the study, the Board recommended that: The Department of Transport require that the initial training syllabus for all ship officers be modified to include demonstration of skills in Bridge Resource Management; The Department of Transport require that all ship officers demonstrate skills in Bridge Resource Management before being issued Continued Proficiency Certificates. 4.1.3 Continued Proficiency and Skill Maintenance The master had retired as a pilot in 1987; however, since 1988, he had been engaged by the vessel owners as master on a casual basis. At the time of the accident, the master's behaviour was found to be consistent with that of a person experiencing some degree of stress and skill decay. The Canadian Coast Guard is currently amending the Certification Regulations and the Safe Manning Regulations to require most Canadian-certificated masters, mates, or engineers to obtain Continued Proficiency Certificates (CPC). Applicants will be required to successfully complete training in Marine Emergency Duties and Simulated Electronic Navigation to be issued a CPC which must be renewed every five years. Further, applicants will need to fulfil certain service requirements, including sea time, within the five years before the application. The regulation pertaining to CPC requirements has been published in the Canada Gazette Part 1 and is expected to come into force in 1996.